The participating GPs generally valued the case management programme that integrates doctors' assistants in the management of patients with heart failure. However, there were diverse opinions about the usefulness and benefit for patients of the different elements of case management.
According to participants, some elements of case management could be used directly and quickly, such as medication review and patients' diaries and booklets. Moreover, telephone monitoring, assessment of health behaviour (ask and assess), geriatric basic assessment, medication review, the patients' diary and home visits are at least partly feasible. However, GPs stated health behaviour counselling (advice, agree and assist) was not feasible and GPs in smaller practices questioned the cost–benefit ratio of some home visits because of the long absence of doctors' assistants from the practice.
GPs reported unchanged or improved relationships with doctors' assistants and improved relationships with patients. There is potential for the approach to be transferred to other chronic conditions, but there are implications for workforce planning and remuneration and the training of doctor's assistants.
In countries with a longer tradition of primary health-care teams, for example, in the UK, changes in roles and identities across professional boundaries in primary care between doctors and nurses created an initial culture of uncertainty among GPs [26
]. In contrast, in our study for Germany (with little skill mix differentiation in primary care), the participating doctors reported that the new concept of delegating tasks to doctors' assistants did not undermine their perceived professional role. These findings need to be interpreted carefully as to their generalizability, as we asked GPs about tasks that were performed mainly by their employed doctors' assistants. First, it is possible that participants were prone to practice-based case management by their voluntary participation in the parental HICMan trial [7
]. Second, the findings of our complementary qualitative study with the doctor's assistants indicated that acceptability of adopting new tasks and roles for patient care in case management was closely linked to the support of the GPs [11
The increasing prevalence of patients with chronic diseases is associated with increasing multimorbidity and complexity [27
]. Internationally, meeting the needs of patients with chronic diseases while containing costs is important for redesigning health-care systems. This is interconnected with issues of skill mix and workforce planning. Shortage of primary care doctors and other health professionals emphasizes the challenge of maintaining an affordable health-care system [28
]. According to Bodenheimer et al
], prevention and management of chronic diseases are best performed by multidisciplinary teams in primary care and associated reforms to payments that reward practices that incorporate multidisciplinary teams. In Germany, the Advisory Council for the Assessment of Trends in German Health Care System echoed in 2007 the same message as the WHO in 2002, in recommending the use of multiprofessional teams applying principles of a CCM [3
At the individual practice level, the principles of both substitution and delegation imply that non-physician health professionals with appropriate training can take over specific tasks while maintaining or improving patient outcomes [8
]. The German Federal Medical Association is opposed to nurse–doctor substitution and favours delegation under the ‘therapeutic responsibility’ of doctors [32
]. For example, community nurses implementing new tasks in cooperation with GPs are currently being evaluated [33
To adapt to the requirements of ambulatory care, the regulations for training of doctors' assistants in Germany were changed in August 2006 focusing on a ‘meta-professional’ approach stressing social skills like communication with the patient and with practice team members while reducing medical aspects of training [34
]. The ‘Institute for Continuous Medical Education’ of the German Professional Organization of GPs has developed apprenticeship training for doctors' assistants in general practice of 200 units aimed at ‘improved support of patients and GPs in general practice’ leading to the certificate ‘care assistant’. Forty units of this curriculum focus on case management and chronic disease management [35
]. However, this new curriculum has not been evaluated yet.
The limitations of the study are that the participating practices were larger than most German practices, although the sample of GPs had a broad range of ages. Therefore, the findings might not reflect the views of GPs working in smaller/solo practices in Germany. Moreover, GPs were taking part in a trial and therefore may differ from other GPs. Opinions in focus groups are expressed within a group setting, and it is possible that they were influenced by the more dominant participants. However, the presence of a moderator helped ensuring that all members were given the opportunity to voice their opinions, and by conducting five separate focus groups the influence of certain individuals was reduced. Since we focused on thematic and content analysis, we did not explore the emotional and linguistic level, which could have given further insights into the motivation and attitudes of the participants. We explored doctors' consultants' views of HICMan [7
], but patients' views are a crucial source of information on the feasibility and acceptability of the case management programme, and are missing in this study.
Conclusion and perspective
Our findings suggest that enhancing the roles of doctors' assistants by incorporating a heart failure case management programme is feasible and acceptable to German GPs. However, we believe that adaptation of the programme, its transferability to other conditions and a payment is crucial for its successful implementation. In the wider international context of primary care practice nursing, the delegation of tasks using tailored case management may be a promising strategy for improving the quality of care for patients with chronic conditions and for patient self-management.